Integrated Health and Social Home Care Services in Catalonia: Professionals’ Perception of its Implementation, Barriers, and Facilitators

Introduction: This study aimed to assess the implementation of integrated social and health home care services (HCS) offered by the Government of Catalonia, and to identify the main barriers and facilitators of integrated HCS. Methods: Analysis of the degree of implementation of integrated social and health HCS perceived by social care services (SCS) and primary health care centers (PHCs) between December 2020 and June 2021 in two phases. First, the perception of integration by social workers within SCS and PHCs was assessed using a screening questionnaire. Then, SCS in counties with the highest integration scores received a customized questionnaire for an in-depth assessment. Results: A total of 105 (100%) SCS and 94 (25%) PHCs answered the screening questionnaire, and 48 (45.7%) SCS received a customized questionnaire. The most frequent barrier identified was the lack of shared protocols, with the most frequent facilitator being the recognition of the importance of integrated HCS. Conclusions: Our study showed that the degree of implementation of integrated health and social HCS offered by the Government of Catalonia was perceived as low. The identified barriers and facilitators can be used to facilitate such implementation. Further studies should include professionals other than social workers in PHC assessments.


Introduction to the questionnaire:
Thank you for accepting our invitation to participate in the baseline assessment of the Integrated Home Care Program.
The questionnaire contains 5 sections.It will take you approximately 10 to 15 minutes to complete.
At the end of each question, you will find a space for remarks in case you wish to add any comments.In order to facilitate the processing of the answers and their interpretation, we kindly ask you to be as clear and concise as possible in your answers, using short sentences and clear and specific language insofar as possible.
Your participation will help us to obtain a picture covering all of Catalonia of your perception and opinion regarding these integrated home care services in your territory.

Thank you for participating! I. Identification details:
 Name of Social Care Services:  Position:  Service/Team: II.Perception and opinion: rate from 0 to 5 the degree of implementation in your territory of the following key aspects of the integrated social and health home care services.
Note: "0" is no or minimal implementation, and "5" is the maximum desirable implementation in your territory Core elements of the integrated social and health home care services Score from 0 to 5 Remarks 1. Individual assessment of integrated social and health care.A comprehensive and integrated assessment is conducted using tools that are both unique to and shared between the two spheres when integrated care is required.

Single individual care plan.
An individual care plan is developed in a collaborative manner, suitable to the teams of professionals in both spheres.

Shared protocols across health and social services.
Collaborative work dynamic with shared protocols across health and social services in different formats (joint complexity route, 24/7 care, management of risks in the home environment, etc.).

Coordination between social and health multidisciplinary teams.
Spaces are created and time is devoted to the work shared between the two spheres, both reactively in terms of the capacity to respond to crisis situations, and proactively by establishing key individuals in both spheres for the III.What score from 0 to 10 would you give to the implementation of the integrated social and health home care services in your territory?
IV.What would you consider the main barriers and facilitators of the integrated home care services in your territory?

Barriers Facilitators
V. We attach a Word document in which you can set out the best practices you are employing in your territory related to the integrated home care services.You can share all practices which you consider to be scalable on the basis of their value in helping to produce better results.
recipient of the care (lead and co-lead caregivers), as well as implementing digital solutions that facilitate a collaborative service (integrated registration systems, shared messaging service, etc.).

Integrated portfolio of services with joint social
and health home care projects.Elements of the portfolio of home care services are incorporated.These are available to and used by both spheres, thereby facilitating direct access to resources and services for both spheres when a need is identified so that they can be prescribed and implemented.

Portfolio of integrated services and evaluation of the catalog of services
Rate from 0 to 5 the degree of implementation in your territory, where "0" indicates no or minimal implementation and "5" the maximum desirable implementation in your territory as a whole.
Note: Answer the questions for which you have information.

Remarks:
2. Individual and integrated care plan Score from 0 to 5 Comments

The person's care plan is unique
The plan specifies the following components: 2. List of identified needs or problems that require intervention.
 Specification of which are the priority problems of the person and their family and main caregiver 3. Definition of objectives agreed upon with any care providers from other spheres  Expectations and objectives of the person and their family regarding the care process 4. Specification of the interventions and strategies that will be carried out.
 Specification of the professionals or the disciplines responsible for their execution 5. Specification of the criteria that will be used to evaluate the results achieved through the plan.
6.The plan is jointly prepared with the person and the team  It is based on the interdisciplinary and integrated assessment of the person and their environment  It is prepared with the person, the social and health interdisciplinary team, and the person's key support network when necessary  It is prepared through a process of shared decision-making 7. The plan is implemented from the very start of the care service provision, and a re-assessment of the plan is conducted within the first 6 weeks and at least once a year, so that it is kept constantly up-to-date.
8. The person can view their plan and keeps the current and up-to-date care plan.
9. The integrated care plan includes actions by the professionals from the various disciplines and services that visit the person at home.
10.The plan is accompanied by a home information file, specifying the key agreements and aspects to be taken into account in relation to the care recipient and their family.

Comments
The facilitating tools for the integrated home care service measured through this indicator are as follows: 1. Definition of the systems for organizing the teams according to the territory of action 2. Collaborative planning of the service among the various agents involved (case conferences, inquiries between teams, etc.).
3. Systems for allocating cases (caseload of the teams) and assignment of the workload according to the amount of support required.
4. Interdisciplinary and multi-agency composition of the various services included in the portfolio of the home care teams.
5. Existence of a communication and messaging system for the practitioners involved in the care process.
6. Assignment of lead and co-lead caregivers for the recipient of the integrated care service.1 7. The team has access to the Integrated Home Care Program's electronic case tracking system, activated by the program's professionals, with the possibility to incorporate multi-platform teleconferences, images, and transmissions.
8. Existence of agile mechanisms for resolving any differences or conflicts of criteria arising between professionals and organizations.A portfolio of integrated home care services exists 2. A brief description of the catalog of services exists, including, as a minimum, a description of the service in question, the objectives, the profile of the users to whom the activities or services are offered, the operating hours, and the personnel responsible for the functional equipment.Activities are described at the individual, family, and community level. 2 3. As part of the Integrated Home Care Program in the territory, an assessment is conducted periodically (at least annually) of the programs described in the integrated catalog of services of all the parties involved in order to identify any need to adapt the program, as well as any other areas for improvement.
4. Existence of a personal platform or folder where the user and caregiver can interact with the key professionals Remarks: 3 2 An alternative classification of the activities could be: preventive, assistance, educational, and community.
3 ADDITIONAL COMMENTS: Below is an explanatory scale setting out the meanings of the scores from 0 to 5, which you may find useful when making your assessments.-The score "0" indicates the minimum score, or not implemented.- The score "1" indicates an initial phase.The processes are not usually documented, and operations are reactive or action is taken when a specific case arises.- The score "2" indicates partially developed.Plans have been established: a strategy has been developed and its implementation has begun, although the processes are inconsistent.This assessment or measurement applies to 30% or more of the people tended to.- The score "3" indicates an established process: defined, standard processes in force, used systematically, susceptible to improvement over time.This assessment applies to 60% or more of the people tended to.- The score "4" indicates a good level of development.Mature: processes have been tested under variable conditions over a period of time, and their impact is beginning to show.This assessment applies to 90% or more of the people tended to.- The score "5" indicates an excellent level of exemplary development: fully integrated into the system and the results for the recipients generally reflect this, with continuous improvement driven by incremental and innovative changes.It would be a best practice to be scaled and implemented throughout Catalonia.
find 5 tables for identifying your perception and opinion regarding the degree of development of the integrated care services in the following areas: care tools (shared protocols, routes, messaging, shared records, etc.)4.Continuity of the care and coordination between multidisciplinary teams

9.
Existence of shared protocols for the home care service (to unify the minimum protocols with the Project Monitoring Commission) 10.Shared care routes for the integrated care service (e.g., complexity route) and application of a territorial functional plan to ensure delivery and continued care under the integrated home care service  Application of the functional plan in relation to the continuity of care with primary health care  Application of the functional plan for continuity of care with the social-health care network  Application of the functional plan for continuity of care with key hospitals  Application of the functional plan for continuity of care with other specialized services, defining the process for coordination of the integrated home care service  Incorporation of volunteers and other community initiatives within the framework of the integrated home care service 2. Conducting case conferences or discussions of cases planned jointly between the social and health care teams (either face-to-face or virtually) 3. Responses to inquiries raised between the different parties involved in the care process (with response times within the established limits) 4. Information provided in the person's transitions between different services 5. Management of differences of opinion among the teams in accordance with established procedures.